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4 . NED <br /> UST SYSTEM RETROFIT OR REPAIR <br /> JUL 18 2018 <br /> (Submit minimum of 3 sets of plans &applications as originals will be retained by EHD) <br /> 1. Site map enclosed? YES N NO [] ENVIRONMENTAL <br /> Hr-pA T" LF.PA.PTMENT <br /> 2. Submit copies of ICC Service Technician and/or Installer's certificate and all manufacturer training certificates for each <br /> person installing or testing any component that is repaired or replaced. Ensure a copy of the "Site Health and Safety <br /> Plan" is available on the jobsite as required by Title 8. <br /> 3. Detailed description of work to be completed. List components to be repaired or replaced and attach a diagram drawn <br /> to scale showing location of repairs and/or replacements. If repairing a component, describe how this will be done. (If <br /> adding piping, UDC's, or other UST equipment, or performing tank top upgrade, use the UST Installation Application <br /> pages 4-8 as necessary for a timely plan review): <br /> •Sawcut, remove and dispose of the concrete at each of two (2) spill <br /> containers. <br /> *Remove and dispose of the existing spill containers. <br /> •Install all Source NA furnished OPW spill containers, swivel adapters, <br /> caps, face seal adapters and jack screw kits. <br /> •Obtain the required CUPA inspection prior to backfill. <br /> •Backfill and restore all concrete removed for this work. <br /> •Obtain all CUPA inspections and provide all CUPA and Air Quality <br /> testing. <br /> 4. List of equipment to be used (Attach manufacturer's specification sheets showing third-party approval): <br /> (2) OP-1 C-2100C-DEVR 5-gallon spill containers <br /> (2) OP-61 SALP-1020-EVR OPW 4" swivel fill adapters <br /> (2) OP-634TT-7085-EVR OPW 4" fill caps <br /> (2) OP-61JSK-44CB Jack screw kit <br /> (2) FSA-400S OPW face seal adapters <br /> EH230038(revised 7-26-2016) 3 <br />